PFD report

ANTHONY STEPHEN CLEVELAND · Prevention of Future Deaths report

Pin Get email alerts Request correction

Issued 14 Sep 2015•Suffolk

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

View original report
Concerns
5

Raised in this report

Recipients
1

Named on the report

Responses found
0

Of 1 recipient

Stated actions
0

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

Open published report

Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised5

  1. Insufficient supervision for immediate recognition of medical problems
    Part of recurring concern: Failure to provide adequate supervision and emergency assistance coverage at recreational activity venues
  2. Lack of qualified first aiders
    Part of recurring concern: Failure to provide adequate first aid where emergency assistance may be neededPart of recurring concern: Unreliable on-site emergency medical and first-aid response arrangements
  3. Inadequate resuscitation attempts following collapse
    Part of recurring concern: Unreliable emergency response to patient collapse
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

No linked response statements

No respondent-stated action or position is clearly linked to these concerns.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Insufficient supervision for immediate recognition of medical problems

Wider context from the report

“It is possible and entirely foreseeable that significant medical problems may arise in an environment where people are exercising and may have underlying medical problems that could predispose them to collapse. Given the severity of the underlying coronary artery disease and subsequent cardiac arrest here it is not possible to say in this particular situation whether this tragic outcome could have been avoided with an earlier and more effective response, but the evidence here was that there was not a level of supervision that enabled the problem to be recognised immediately, and neither was there an adequate attempt to resuscitate once it had been established that a person had collapsed. There was also evidence of absence of adequate risk assessment in respect of gym users, a lack of qualified first aiders, and an absence of formalised national guidance on risk assessment in fitness centres and gyms. There was evidence that there was HSE guidance on swimming pool operations, but there is not for other facilities and it was felt that this would help the industry, particularly given the proliferation of such gymnasia in recent years, if there was formalised national guidance on risk assessment in fitness centres and gyms. ”

Is this part of a recurring concern?

Yes — Failure to provide adequate supervision and emergency assistance coverage at recreational activity venues.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Lack of qualified first aiders

Wider context from the report

“It is possible and entirely foreseeable that significant medical problems may arise in an environment where people are exercising and may have underlying medical problems that could predispose them to collapse. Given the severity of the underlying coronary artery disease and subsequent cardiac arrest here it is not possible to say in this particular situation whether this tragic outcome could have been avoided with an earlier and more effective response, but the evidence here was that there was not a level of supervision that enabled the problem to be recognised immediately, and neither was there an adequate attempt to resuscitate once it had been established that a person had collapsed. There was also evidence of absence of adequate risk assessment in respect of gym users, a lack of qualified first aiders, and an absence of formalised national guidance on risk assessment in fitness centres and gyms. There was evidence that there was HSE guidance on swimming pool operations, but there is not for other facilities and it was felt that this would help the industry, particularly given the proliferation of such gymnasia in recent years, if there was formalised national guidance on risk assessment in fitness centres and gyms. ”

Is this part of a recurring concern?

Yes — Failure to provide adequate first aid where emergency assistance may be needed; Unreliable on-site emergency medical and first-aid response arrangements.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Inadequate resuscitation attempts following collapse

Wider context from the report

“It is possible and entirely foreseeable that significant medical problems may arise in an environment where people are exercising and may have underlying medical problems that could predispose them to collapse. Given the severity of the underlying coronary artery disease and subsequent cardiac arrest here it is not possible to say in this particular situation whether this tragic outcome could have been avoided with an earlier and more effective response, but the evidence here was that there was not a level of supervision that enabled the problem to be recognised immediately, and neither was there an adequate attempt to resuscitate once it had been established that a person had collapsed. There was also evidence of absence of adequate risk assessment in respect of gym users, a lack of qualified first aiders, and an absence of formalised national guidance on risk assessment in fitness centres and gyms. There was evidence that there was HSE guidance on swimming pool operations, but there is not for other facilities and it was felt that this would help the industry, particularly given the proliferation of such gymnasia in recent years, if there was formalised national guidance on risk assessment in fitness centres and gyms. ”

Is this part of a recurring concern?

Yes — Unreliable emergency response to patient collapse.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Lack of adequate risk assessment for gym users

Wider context from the report

“It is possible and entirely foreseeable that significant medical problems may arise in an environment where people are exercising and may have underlying medical problems that could predispose them to collapse. Given the severity of the underlying coronary artery disease and subsequent cardiac arrest here it is not possible to say in this particular situation whether this tragic outcome could have been avoided with an earlier and more effective response, but the evidence here was that there was not a level of supervision that enabled the problem to be recognised immediately, and neither was there an adequate attempt to resuscitate once it had been established that a person had collapsed. There was also evidence of absence of adequate risk assessment in respect of gym users, a lack of qualified first aiders, and an absence of formalised national guidance on risk assessment in fitness centres and gyms. There was evidence that there was HSE guidance on swimming pool operations, but there is not for other facilities and it was felt that this would help the industry, particularly given the proliferation of such gymnasia in recent years, if there was formalised national guidance on risk assessment in fitness centres and gyms. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Absence of formalised national guidance on risk assessment in fitness centres and gyms

Wider context from the report

“It is possible and entirely foreseeable that significant medical problems may arise in an environment where people are exercising and may have underlying medical problems that could predispose them to collapse. Given the severity of the underlying coronary artery disease and subsequent cardiac arrest here it is not possible to say in this particular situation whether this tragic outcome could have been avoided with an earlier and more effective response, but the evidence here was that there was not a level of supervision that enabled the problem to be recognised immediately, and neither was there an adequate attempt to resuscitate once it had been established that a person had collapsed. There was also evidence of absence of adequate risk assessment in respect of gym users, a lack of qualified first aiders, and an absence of formalised national guidance on risk assessment in fitness centres and gyms. There was evidence that there was HSE guidance on swimming pool operations, but there is not for other facilities and it was felt that this would help the industry, particularly given the proliferation of such gymnasia in recent years, if there was formalised national guidance on risk assessment in fitness centres and gyms. ”

Is this part of a recurring concern?

Yes — Unreliable guidance and communication for safety risk assessments.

Open source report
Back to top

Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026